Healthcare Provider Details

I. General information

NPI: 1881688059
Provider Name (Legal Business Name): PINE HAVEN CHRISTIAN HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 HAVEN DRIVE
SHEBOYGAN FALLS WI
53085
US

IV. Provider business mailing address

531 GIDDINGS AVE PINE HAVEN CHRISTIAN HOME INC
SHEBOYGAN FALLS WI
53085-1707
US

V. Phone/Fax

Practice location:
  • Phone: 920-467-2401
  • Fax: 920-467-7273
Mailing address:
  • Phone: 920-467-2401
  • Fax: 920-467-7273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number356
License Number StateWI

VIII. Authorized Official

Name: MARTIN HALVERSON
Title or Position: CFO
Credential:
Phone: 920-550-5257